KAPLAN RN EXIT EXAM 2023-2024 ACTUAL EXAM
160 QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+
The nurse cares for the client diagnosed with lung cancer. The family states that
the client has become confused and that urinary output has decreased during the
previous 24 hours. Which finding MOST concerns the nurse?
- 2+ pitting pretibial edema.
- Sodium 128 mEq/L.
- Weight gain of 2 kg in 24 hours.
- Urine specific gravity 1.008. 1) Assessment: outcome desired but not priority;
edema not seen with SIADH even though water is retained; needs to be monitored
2) CORRECT – Assessment: outcome desired and priority; normal sodium range is
135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically
depressed with increased risk of seizures
3) Asssessment: outcome desired but not priority; indicates fluid retention, not as
important as hyponatremia; important to watch trends in weight
4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with
SIADH, urine will have high concentration and specific gravity due to excess ADH
secretion
The home care nurse cares for a client who is diagnosed with hypertension and
mild depression. The client’s daughter states that her mother has been falling
frequently. WWhich response by the nurse is BEST? - “Let’s get your mother a walker.”
- “Do you think it’s time to put your mother in a nursing home?”
- “When does your mother fall?”
- “Does your mother seem to be more confused lately?” 1) Implementation:
outcome not desired; need to assess first
2) Assessment: outcome not priority; “yes/no” question; doesn’t help determine the
problem
3) CORRECT – Assessment: outcome priority; nurse needs to determine what the
problem is before implementing; recent history of falling is most important
contributor to increased risk of falls
4) Assessment: outcome not priority; “yes/no” question is non-therapeutic; need to
assess; may be a contributing factor
A femoral angiogram is scheduled for a client. It is MOST important for the nurse
to take which action prior to the angiogram? - Clean and shave the catheter insertion-site area.
- Locate and note the presence of peripheral pulses.
- Encourage the client to increase oral fluid intake.
- Teach coughing and deep-breathing exercises. 1) Implementation: outcome
not desired; cleansing may be done according to facility policy; shaving may not
be recommended due to possible abrasions and increased risk of infection
2) CORRECT – Assessment: outcome desired and priority; pulse location may be
marked according to facility policy; important to get baseline assessment of color,
motion, temperature and sensitivity of extremities as well as strength and equality
of pulses
3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause
possible nausea; fluid intake should be increased after procedure to clear dye and
reduce risk of renal toxicity
4) Implementation: outcome desired but not highest priority; not at greatly
increased risk for atelectasis
A child sustains a crushing chest injury in a car accident. In the emergency room,
an endotracheal tube is inserted. Several hours later the nurse enters the client’s
room and finds the child in respiratory distress. It is MOST important for the nurse
to take which action prior to the angiogram?
- Observe the color of the client’s fingernail beds.
- Assess the client’s blood pressure in both arms.
- Listen to the client’s breath sounds.
- Assess for intercostal retractions. 1) Assessment: outcome desired but not
priority; cyanosis is a late sign of respiratory distress; central cyanosis will occur
later than peripheral cyanosis
2) Assessment: outcome not desired; priority is to assess respiratory status; blood
pressure may change due to decreased arterial oxygen levels; priority is to correct
underlying problem
3) CORRECT – Assessment: outcome priority; will give early and clearest
indication of respiratory status, will hear changes with narrowed airways, fluid in
alveoli or pneumothorax
4) Assessment: outcome desired but not priority; late indication of respiratory
distress; intercostal muscles are accessory muscles
The nurse cares for an elderly man diagnosed with Alzheimer’s disease. It is
MOST important for the nurse to take which action?
- Leave the television on all day in the client’s room.
- Frequently inform the client of the room and bathroom location.
- Provide the client with newspapers and magazines.
- Assign a staff member to check on the client every 15 minutes. 1)
Implementation: outcome not desired; does not address orientation needs; risk of
overstimulation; television should be on intermittently
2) CORRECT – Implementation: outcome desired; provides for safety needs and
frequent orientation
3) Implementation: outcome not priority; does not address safety needs or
orientation
4) Implementation: outcome desired not priority; addresses safety but not
orientation or stimulation needs
The nurse is responsible for triage of injured residents of an apartment building
that collapsed during a tornado. Which client should the emergency personnel see
FIRST? - A 38-year-old client with potential fracture left femur. Blood pressure 110/78,
pulse 92/minute, shallow respirations at 16/minute.